You may never deal directly with a claims examiner, but these insurance professionals have a big say in whether your insurer covers losses from accidents or illness. Claims examiners evaluate insurance claims and applications, and follow up on the work of insurance adjusters to protect insurers from unnecessary financial loss. Growth in the industry from 2010 to 2020 will be strongest in health insurance, as medical costs rise and federal mandates will require individuals to buy medical coverage.

Review

A key role of claims examiners is to review filings, as well as findings, of other claims professionals. After adjusters submit claims, examiners look at the documentation to make sure that the claimants and adjusters followed company guidelines. Examiners are called on particularly in complex or large cases that involve potential major financial payouts for insurers. Claims examiners also focus on questionable claims to determine whether payment is warranted. Examiners’ roles vary by company type. Examiners who work for health insurers evaluate whether costs are reasonable, while life insurance examiners review causes of death.

Payment Policies

Part of the claims examiner's role entails settling cases or referring them for further investigation. If an examiner decides a filing has merit, he pays and processes the claim. An examiner who finds that a health treatment was unnecessary, or a cause of death was unclear, refers the claim to an investigator. To ensure insurance companies keep enough money to pay claims, examiners study, adjust or make recommendations on cash reserves. Examiners also review coverage applications to spot serious conditions or illnesses that pose high risks for the insurer.

Administration

Data entry and other administrative tasks are part of the job for claims examiners. They enter claim payments, reserves and new claims with accompanying file documents into company computer systems. Also, they organize and maintain records of settled claims and keep inventories of claims that require additional analysis. Finally, they verify and analyze data the company uses to settle claims, with an eye on proving that claims are valid and payments are made based on company practices and procedures.

Outreach

Claims examiners don't work only with computers, data sets and internal company investigators. Their role in proving claims means health insurance examiners may need to interview claimants and their employers for additional information on invoices. Health insurance and life insurance examiners often have to speak with doctors or other health care professionals to get more details on treatments or causes of death. In cases that involve legal claims, life insurance examiners meet with company attorneys to discuss cases.

Workplace

Claims examiners work for a variety of businesses. Numbers from the U.S. Bureau of Labor Statistics show that insurance carriers employed 32 percent of examiners in 2010, for the biggest share of employment in the field. Another 18 percent of claims examiners worked for the federal government, and 17 percent worked for insurance-related businesses. While claims examiners who work for insurers investigate and determine whether settlement is reasonable, claims examiners who work in business offices of medical or dental practices have different responsibilities. They obtain patient information such as medical records and test results and submit invoices to insurers for payment.

Skills

To fill their roles, claims examiners need several skills. Because they read thousands of documents to back up claims, examiners must have excellent reading comprehension. Good writing skills are also a must, because claims examiners file written reports on their findings. Critical thinking and decision-making give examiners the logic and reasoning to evaluate and resolve claims. Negotiating skills are important, particularly when two parties differ over the validity of a filing or the information needed to settle a claim. Employers also look for examiners who understand medical terms and have paralegal or investigative experience.